document_title: Health insurance in the United States

question_text: when did health insurance start in the united states

question_tokens: when did health insurance start in the united states

root

text: Health insurance in the United States

text: Enrollment and the uninsured[edit]

text: Trends in private coverage[edit]

text: The proportion of non-elderly individuals with employer-sponsored cover fell from 66% in 2000 to 56% in 2010, then stabilized following the passage of the Affordable Care Act. Employees who worked part time (less than 30 hours a week) were less likely to be offered coverage by their employer than were employees who worked full time (21% vs. 72%).[5]

tag: p

text: A major trend in employer sponsored cover has been increasing premiums, deductibles, and co-payments for medical services, and increasing the costs of using out-of-network health providers rather than in-network providers.[6]

text: Trends in public coverage[edit]

text: Public insurance cover increased from 2000–2010 in part because of an aging population and an economic downturn in the latter part of the decade. Funding for Medicaid and CHIP expanded significantly under the 2010 health reform bill.[7] The proportion of individuals covered by Medicaid increased from 10.5% in 2000 to 14.5% in 2010 and 20% in 2015. The proportion covered by Medicare increased from 13.5% in 2000 to 15.9% in 2010, then decreased to 14% in 2015.[3][8]

text: Status of the uninsured[edit]

text: The uninsured proportion was stable at 14–15% from 1990 to 2008, then rose to a peak of 18% in Q3 2013 and rapidly fell to 11% in 2015.[9] The proportion without insurance has stabilized at 9%.[4]

text: A 2011 study found that there were 2.1 million hospital stays for uninsured patients, accounting for 4.4% ($17.1 billion) of total aggregate inpatient hospital costs in the United States.[10] The costs of treating the uninsured must often be absorbed by providers as charity care, passed on to the insured via cost-shifting and higher health insurance premiums, or paid by taxpayers through higher taxes.[11]

text: Death[edit]

text: Since people who lack health insurance are unable to obtain timely medical care, they have a 40% higher risk of death in any given year than those with health insurance, according to a study published in the American Journal of Public Health. The study estimated that in 2005 in the United States, there were 45,000 deaths associated with lack of health insurance.[12] A 2008 systematic review found consistent evidence that health insurance increased utilization of services and improved health.[13]

text: A Johns Hopkins Hospital study found that heart transplant complications occurred most often amongst the uninsured, and that patients who had private health plans fared better than those covered by Medicaid or Medicare.[14] Gallup issued a report in July 2014 stating that the uninsured rate for adults 18 and over declined from 18% in 2013 to 13.4% by in 2014, largely because there were new coverage options and market reforms under the Affordable Care Act.[15] Rand Corporation had similar findings.[16]

text: Reform[edit]

text: The Affordable Care Act of 2010 was designed primarily to extend health coverage to those without it by expanding Medicaid, creating financial incentives for employers to offer coverage, and requiring those without employer or public coverage to purchase insurance in newly created health insurance exchanges. The CBO has estimated that roughly 33 million who would have otherwise been uninsured will receive coverage because of the act by 2022.[17]

text: History[edit]

text: Accident insurance was first offered in the United States by the Franklin Health Assurance Company of Massachusetts. This firm, founded in 1850, offered insurance against injuries arising from railroad and steamboat accidents. Sixty organizations were offering accident insurance in the US by 1866, but the industry consolidated rapidly soon thereafter. While there were earlier experiments, sickness coverage in the US effectively dates from 1890. The first employer-sponsored group disability policy was issued in 1911, but this plan's primary purpose was replacing wages lost because the worker was unable to work, not medical expenses.[18]

text: Before the development of medical expense insurance, patients were expected to pay all other health care costs out of their own pockets, under what is known as the fee-for-service business model. During the middle to late 20th century, traditional disability insurance evolved into modern health insurance programs. Today, most comprehensive private health insurance programs cover the cost of routine, preventive, and emergency health care procedures, and also most prescription drugs, but this was not always the case. The rise of private insurance was accompanied by the gradual expansion of public insurance programs for those who could not acquire coverage through the market.

text: Hospital and medical expense policies were introduced during the first half of the 20th century. During the 1920s, individual hospitals began offering services to individuals on a pre-paid basis, eventually leading to the development of Blue Cross organizations in the 1930s.[18] The first employer-sponsored hospitalization plan was created by teachers in Dallas, Texas in 1929.[19] Because the plan only covered members' expenses at a single hospital, it is also the forerunner of today's health maintenance organizations (HMOs).[19][20][21]

text: In the 1930s, The Roosevelt Administration explored possibilities for creating a national health insurance program, while it was designing the Social Security system. But it abandoned the project because the American Medical Association (AMA) fiercely opposed it, along with all forms of health insurance at that time.[22]

text: The rise of employer-sponsored coverage[edit]

text: Employer-sponsored health insurance plans dramatically expanded as a direct result of wage controls imposed by the federal government during World War II.[19] The labor market was tight because of the increased demand for goods and decreased supply of workers during the war. Federally imposed wage and price controls prohibited manufacturers and other employers from raising wages enough to attract workers. When the War Labor Board declared that fringe benefits, such as sick leave and health insurance, did not count as wages for the purpose of wage controls, employers responded with significantly increased offers of fringe benefits, especially health care coverage, to attract workers.[19]

text: President Harry S. Truman proposed a system of public health insurance in his November 19, 1945, address. He envisioned a national system that would be open to all Americans, but would remain optional. Participants would pay monthly fees into the plan, which would cover the cost of any and all medical expenses that arose in a time of need. The government would pay for the cost of services rendered by any doctor who chose to join the program. In addition, the insurance plan would give cash to the policy holder to replace wages lost because of illness or injury. The proposal was quite popular with the public, but it was fiercely opposed by the Chamber of Commerce, the American Hospital Association, and the AMA, which denounced it as "socialism".[23]

text: Foreseeing a long and costly political battle, many labor unions chose to campaign for employer-sponsored coverage, which they saw as a less desirable but more achievable goal, and as coverage expanded the national insurance system lost political momentum and ultimately failed to pass. Using health care and other fringe benefits to attract the best employees, private sector, white-collar employers nationwide expanded the U.S. health care system. Public sector employers followed suit in an effort to compete. Between 1940 and 1960, the total number of people enrolled in health insurance plans grew seven-fold, from 20,662,000 to 142,334,000,[24] and by 1958, 75% of Americans had some form of health coverage.[25]

text: Kerr-Mills Act[edit]

text: Still, private insurance remained unaffordable or simply unavailable to many, including the poor, the unemployed, and the elderly. Before 1965, only half of seniors had health care coverage, and they paid three times as much as younger adults, while having lower incomes.[26] Consequently, interest persisted in creating public health insurance for those left out of the private marketplace.

text: The 1960 Kerr-Mills Act provided matching funds to states assisting patients with their medical bills. In the early 1960s, Congress rejected a plan to subsidize private coverage for people with Social Security as unworkable, and an amendment to the Social Security Act creating a publicly run alternative was proposed. Finally, President Lyndon B. Johnson signed the Medicare and Medicaid programs into law in 1965, creating publicly run insurance for the elderly and the poor.[27] Medicare was later expanded to cover people with disabilities, end-stage renal disease, and ALS.

text: Towards universal coverage[edit]

text: Persistent lack of insurance among many working Americans continued to create pressure for a comprehensive national health insurance system. In the early 1970s, there was fierce debate between two alternative models for universal coverage. Senator Ted Kennedy proposed a universal single-payer system, while President Nixon countered with his own proposal based on mandates and incentives for employers to provide coverage while expanding publicly run coverage for low-wage workers and the unemployed. Compromise was never reached, and Nixon's resignation and a series of economic problems later in the decade diverted Congress's attention away from health reform.

text: Shortly after his inauguration, President Clinton offered a new proposal for a universal health insurance system. Like Nixon's plan, Clinton's relied on mandates, both for individuals and for insurers, along with subsidies for people who could not afford insurance. The bill would have also created "health-purchasing alliances" to pool risk among multiple businesses and large groups of individuals. The plan was staunchly opposed by the insurance industry and employers' groups and received only mild support from liberal groups, particularly unions, which preferred a single payer system. Ultimately it failed after the Republican takeover of Congress in 1994.[28]

text: Finally achieving universal health coverage remained a top priority among Democrats, and passing a health reform bill was one of the Obama Administration's top priorities. The Patient Protection and Affordable Care Act was similar to the Nixon and Clinton plans, mandating coverage, penalizing employers who failed to provide it, and creating mechanisms for people to pool risk and buy insurance collectively.[7] Earlier versions of the bill included a publicly run insurer that could compete to cover those without employer sponsored coverage (the so-called public option), but this was ultimately stripped to secure the support of moderates. The bill passed the Senate in December 2009 with all Democrats voting in favor and the House in March 2010 with the support of most Democrats. Not a single Republican voted in favor of it either time.

text: Public health care coverage[edit]

text: Public programs provide the primary source of coverage for most seniors and also low-income children and families who meet certain eligibility requirements. The primary public programs are Medicare, a federal social insurance program for seniors (generally persons aged 65 and over) and certain disabled individuals; Medicaid, funded jointly by the federal government and states but administered at the state level, which covers certain very low income children and their families; and CHIP, also a federal-state partnership that serves certain children and families who do not qualify for Medicaid but who cannot afford private coverage. Other public programs include military health benefits provided through TRICARE and the Veterans Health Administration and benefits provided through the Indian Health Service. Some states have additional programs for low-income individuals.[29] In 2011, approximately 60 percent of stays were billed to Medicare and Medicaid—up from 52 percent in 1997.[30]

text: Medicare[edit]

text: In the United States, Medicare is a federal social insurance program that provides health insurance to people over the age of 65, individuals who become totally and permanently disabled, end stage renal disease (ESRD) patients, and people with ALS. Recent research has found that the health trends of previously uninsured adults, especially those with chronic health problems, improves once they enter the Medicare program.[31] Traditional Medicare requires considerable cost-sharing, but ninety percent of Medicare enrollees have some kind of supplemental insurance - either employer-sponsored or retiree coverage, Medicaid, or a private Medigap plan – that covers some or all of their cost-sharing.[32] With supplemental insurance, Medicare ensures that its enrollees have predictable, affordable health care costs regardless of unforeseen illness or injury.

text: As the population covered by Medicare grows, its costs are projected to rise from slightly over 3 percent of GDP to over 6 percent, contributing substantially to the federal budget deficit.[33] In 2011, Medicare was the primary payer for an estimated 15.3 million inpatient stays, representing 47.2 percent ($182.7 billion) of total aggregate inpatient hospital costs in the United States.[10] The Affordable Care Act took some steps to reduce Medicare spending, and various other proposals are circulating to reduce it further.

text: Medicare Advantage[edit]

text: Medicare Advantage plans expand the health insurance options for people with Medicare. Medicare Advantage was created under the Balanced Budget Act of 1997, with the intent to better control the rapid growth in Medicare spending, as well as to provide Medicare beneficiaries more choices. But on average, Medicare Advantage plans cost 12% more than traditional Medicare.[34] The ACA took steps to align payments to Medicare Advantage plans with the cost of traditional Medicare.

text: There is some evidence that Medicare Advantage plans select patients with low risk of incurring major medical expenses to maximize profits at the expense of traditional Medicare.[35]

text: Medicare Part D[edit]

text: Medicare Part D provides a private insurance option to allow Medicare beneficiaries to purchase subsidized coverage for the costs of prescription drugs. It was enacted as part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and went into effect on January 1, 2006.[36]

text: Medicaid[edit]

text: Medicaid was instituted for the very poor in 1965. Since enrollees must pass a means test, Medicaid is a social welfare or social protection program rather than a social insurance program. Despite its establishment, the percentage of US residents who lack any form of health insurance has increased since 1994.[37] It has been reported that the number of physicians accepting Medicaid has decreased in recent years because of lower reimbursement rates.[38]

text: The Affordable Care Act dramatically expanded Medicaid. The program will now cover everyone with incomes under 133% of the federal poverty level who does not qualify for Medicare, provided this expansion of coverage has been accepted by the state where the person resides. Meanwhile, Medicaid benefits must be the same as the essential benefit in the newly created state exchanges. The federal government will fully fund the expansion of Medicaid initially, with some of the financial responsibility gradually devolving back to the states by 2020.

text: In 2011, there were 7.6 million hospital stays billed to Medicaid, representing 15.6% (approximately $60.2 billion) of total aggregate inpatient hospital costs in the United States.[10]

text: Children's Health Insurance Program (SCHIP)[edit]

text: The Children's Health Insurance Program (CHIP) is a joint state/federal program to provide health insurance to children in families who earn too much money to qualify for Medicaid, yet cannot afford to buy private insurance. The statutory authority for CHIP is under title XXI of the Social Security Act. CHIP programs are run by the individual states according to requirements set by the federal Centers for Medicare and Medicaid Services, and may be structured as independent programs separate from Medicaid (separate child health programs), as expansions of their Medicaid programs (CHIP Medicaid expansion programs), or combine these approaches (CHIP combination programs). States receive enhanced federal funds for their CHIP programs at a rate above the regular Medicaid match.

text: Military health benefits[edit]

text: Health benefits are provided to active duty service members, retired service members and their dependents by the Department of Defense Military Health System (MHS). The MHS consists of a direct care network of Military Treatment Facilities and a purchased care network known as TRICARE. Additionally, veterans may also be eligible for benefits through the Veterans Health Administration.

text: Indian health service[edit]

text: The Indian Health Service (IHS) provides medical assistance to eligible American Indians at IHS facilities, and helps pay the cost of some services provided by non-IHS health care providers.[29]

text: State risk pools[edit]

text: In 1976, some states began providing guaranteed-issuance risk pools, which enable individuals who are medically uninsurable through private health insurance to purchase a state-sponsored health insurance plan, usually at higher cost. Minnesota was the first to offer such a plan; 34 states (Alabama, Alaska, Arkansas, California, Colorado, Connecticut, Florida, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Mexico, North Carolina, North Dakota, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, West Virginia, Wisconsin, Wyoming) now offer them. Plans vary greatly from state to state, both in their costs and benefits to consumers and in their methods of funding and operations. They serve a very small portion of the uninsurable market—about 182,000 people in the U.S. as of 2004,[39] and about 200,000 in 2008.[40]

text: These risk pools allow people with pre-existing conditions such as cancer, diabetes, heart disease or other chronic illnesses to be able to switch jobs or seek self-employment without fear of being without health care benefits.[41] However, the plans are expensive, with premiums that can be double the average policy, and the pools currently cover only 1 in 25 of the so-called "uninsurable" population.[42] Additionally, even plans which are not expensive can leave those enrolled with little real health insurance beyond "catastrophic" insurance; for example, one insurance plan through Minnesota's high-risk pool, while costing only $215 per quarter, includes a $10,000 deductible with no preventative or other health care covered unless and until the enrollee has spent $10,000 of their own money during the year on health care.[43] Very sick people can accumulate large medical bills during mandatory waiting periods before their medical expenses are covered, and there are often lifetime expenditure caps (maximums), after which the risk pool no longer pays for any medical expenses.[44]

text: Efforts to pass a national pool have been unsuccessful, but some federal tax money has been awarded to states to innovate and improve their plans. With the Patient Protection and Affordable Care Act, effective by 2014, it will be easier for people with pre-existing conditions to afford regular insurance, since all insurers will be fully prohibited from discriminating against or charging higher rates for any individuals based on pre-existing medical conditions.[45][46]

text: Pre-existing Condition Insurance Plan[edit]

text: The Pre-existing Condition Insurance Plan, or PCIP, is a transitional program created in the Patient Protection and Affordable Care Act (PPACA). Those eligible for PCIP are citizens of the United States or those legally residing in the U.S., who have been uninsured for the last 6 months and "have a pre-existing condition or have been denied health coverage because of their health condition." However, if one has health insurance or is enrolled in a state high risk pool, they are not eligible for PCIP, even if that coverage does not cover their medical condition. PCIP is run by the individual states or through the U.S. Department of Health and Human Services, which has a contract with the Government Employees Health Association, or GEHA, to administer benefits. Both will be funded by the federal government and provide three plan options. These options are the standard, extended, and the Health Savings Account option. PCIP only covers the individual enrollee and does not include family members or dependents. In 2014, the Affordable Care Act provision banning discrimination based on pre-existing conditions will be implemented and PCIP enrollees will be transitioned into new state-based health care exchanges.[47][48][49]

text: Private health care coverage[edit]

text: Private health insurance may be purchased on a group basis (e.g., by a firm to cover its employees) or purchased by individual consumers. Most Americans with private health insurance receive it through an employer-sponsored program. According to the United States Census Bureau, some 60% of Americans are covered through an employer, while about 9% purchase health insurance directly.[50] Private insurance was billed for 12.2 million inpatient hospital stays in 2011, incurring approximately 29% ($112.5 billion) of the total aggregate inpatient hospital costs in the United States.[10]

text: The US has a joint federal and state system for regulating insurance, with the federal government ceding primary responsibility to the states under the McCarran-Ferguson Act. States regulate the content of health insurance policies and often require coverage of specific types of medical services or health care providers.[51][52] State mandates generally do not apply to the health plans offered by large employers, because of the preemption clause of the Employee Retirement Income Security Act.

text: Employer sponsored[edit]

text: Employer-sponsored health insurance is paid for by businesses on behalf of their employees as part of an employee benefit package. Most private (non-government) health coverage in the US is employment-based. Nearly all large employers in America offer group health insurance to their employees.[53] The typical large-employer PPO plan is typically more generous than either Medicare or the Federal Employees Health Benefits Program Standard Option.[54]

text: The employer typically makes a substantial contribution towards the cost of coverage. Typically, employers pay about 85% of the insurance premium for their employees, and about 75% of the premium for their employees' dependents. The employee pays the remaining fraction of the premium, usually with pre-tax/tax-exempt earnings. These percentages have been stable since 1999.[55] Health benefits provided by employers are also tax-favored: Employee contributions can be made on a pre-tax basis if the employer offers the benefits through a section 125 cafeteria plan.

text: Workers who receive employer-sponsored health insurance tend to be paid less in cash wages than they would be without the benefit, because of the cost of insurance premiums to the employer and the value of the benefit to the worker. The value to workers is generally greater than the wage reduction because of economies of scale, a reduction in adverse selection pressures on the insurance pool (premiums are lower when all employees participate rather than just the sickest), and reduced income taxes.[19] Disadvantages to workers include disruptions related to changing jobs, the regressive tax effect (high-income workers benefit far more from the tax exemption for premiums than low-income workers), and increased spending on healthcare.[19]

text: Costs for employer-paid health insurance are rising rapidly: between 2001 and 2007, premiums for family coverage have increased 78%, while wages have risen 19% and inflation has risen 17%, according to a 2007 study by the Kaiser Family Foundation.[56] Employer costs have risen noticeably per hour worked, and vary significantly. In particular, average employer costs for health benefits vary by firm size and occupation. The cost per hour of health benefits is generally higher for workers in higher-wage occupations, but represent a smaller percentage of payroll.[57] The percentage of total compensation devoted to health benefits has been rising since the 1960s.[58] Average premiums, including both the employer and employee portions, were $4,704 for single coverage and $12,680 for family coverage in 2008.[55][59]

text: However, in a 2007 analysis, the Employee Benefit Research Institute concluded that the availability of employment-based health benefits for active workers in the US is stable. The "take-up rate," or percentage of eligible workers participating in employer-sponsored plans, has fallen somewhat, but not sharply. EBRI interviewed employers for the study, and found that others might follow if a major employer discontinued health benefits. Effective by January 1, 2014, the Patient Protection and Affordable Care Act will impose a $2000 per employee tax penalty on employers with over 50 employees who do not offer health insurance to their full-time workers. (In 2008, over 95% of employers with at least 50 employees offered health insurance.[60])[61] On the other hand, public policy changes could also result in a reduction in employer support for employment-based health benefits.[62]

text: Although much more likely to offer retiree health benefits than small firms, the percentage of large firms offering these benefits fell from 66% in 1988 to 34% in 2002.[53]

text: Small employer group coverage[edit]

text: According to a 2007 study, about 59% of employers at small firms (3-199 workers) in the US provide employee health insurance. The percentage of small firms offering coverage has been dropping steadily since 1999. The study notes that cost remains the main reason cited by small firms who do not offer health benefits.[63] Small firms that are new are less likely to offer coverage than ones that have been in existence for a number of years. For example, using 2005 data for firms with fewer than 10 employees, 43% of those that had been in existence at least 20 years offered coverage, but only 24% of those that had been in existence less than 5 years did. The volatility of offer rates from year to year also appears to be higher for newer small businesses.[64]

text: The types of coverage available to small employers are similar to those offered by large firms, but small businesses do not have the same options for financing their benefit plans. In particular, self-funded health care (whereby an employer provides health or disability benefits to employees with its own funds rather than contracting an insurance company[65]) is not a practical option for most small employers.[66] A RAND Corporation study published in April 2008 found that the cost of health care coverage places a greater burden on small firms, as a percentage of payroll, than on larger firms.[67] A study published by the American Enterprise Institute in August 2008 examined the effect of state benefit mandates on self-employed individuals, and found that "the larger the number of mandates in a state, the lower the probability that a self-employed person will be a significant employment generator."[68] Beneficiary cost sharing is, on average, higher among small firms than large firms.[69]

text: When small group plans are medically underwritten, employees are asked to provide health information about themselves and their covered family members when they apply for coverage. When determining rates, insurance companies use the medical information on these applications. Sometimes they will request additional information from an applicant's physician or ask the applicants for clarification.[70]

text: States regulate small group premium rates, typically by placing limits on the premium variation allowable between groups (rate bands). Insurers price to recover their costs over their entire book of small group business while abiding by state rating rules.[71] Over time, the effect of initial underwriting "wears off" as the cost of a group regresses towards the mean. Recent claim experience - whether better or worse than average - is a strong predictor of future costs in the near term. But the average health status of a particular small employer group tends to regress over time towards that of an average group.[72] The process used to price small group coverage changes when a state enacts small group reform laws.[73]

text: Insurance brokers play a significant role in helping small employers find health insurance, particularly in more competitive markets. Average small group commissions range from 2 percent to 8 percent of premiums. Brokers provide services beyond insurance sales, such as assisting with employee enrollment and helping to resolve benefits issues.[74]

text: College-sponsored health insurance for students[edit]

text: Many colleges, universities, graduate schools, professional schools and trade schools offer a school-sponsored health insurance plan. Many schools require that you enroll in the school-sponsored plan unless you are able to show that you have comparable coverage from another source.

text: Effective group health plan years beginning after September 23, 2010, if an employer-sponsored health plan allows employees' children to enroll in coverage, then the health plan must allow employees' adult children to enroll as well as long as the adult child is not yet age 26. Some group health insurance plans may also require that the adult child not be eligible for other group health insurance coverage, but only before 2014.[75]

text: This extension of coverage will help cover one in three young adults, according to White House documents.

text: Federal employees health benefit plan (FEHBP)[edit]

text: In addition to such public plans as Medicare and Medicaid, the federal government also sponsors a health benefit plan for federal employees—the Federal Employees Health Benefits Program (FEHBP). FEHBP provides health benefits to full-time civilian employees. Active-duty service members, retired service members and their dependents are covered through the Department of Defense Military Health System (MHS). FEHBP is managed by the federal Office of Personnel Management.

text: "Portability" of group coverage[edit]

text: Two federal laws address the ability of individuals with employment-based health insurance coverage to maintain coverage.

text: The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) enables certain individuals with employer-sponsored coverage to extend their coverage if certain "qualifying events" would otherwise cause them to lose it. Employers may require COBRA-qualified individuals to pay the full cost of coverage, and coverage cannot be extended indefinitely. COBRA only applies to firms with 20 or more employees, although some states also have "mini-COBRA" laws that apply to small employers.

text: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides for forms of both "group-to-group" and "group-to-individual" portability. When an individual moves from one employer's benefit plan to another's, the new plan must count coverage under the old plan against any waiting period for pre-existing conditions, as long as there is not a break in coverage of more than 63 days between the two plans. When certain qualified individuals lose group coverage altogether, they must be guaranteed access to some form of individual coverage. To qualify, they must have at least 18 months of prior continuous coverage. The details of access and the price of coverage are determined on a state-by-state basis.

text: Association group health insurance[edit]

text: Regular health insurance is sometimes available to members of associations. Associations such as the American Bar Association offer health insurance to their members,[not in citation given] using an established insurance company to write the policies for a group plan.[76]

text: Individually purchased[edit]

text: According to the US Census Bureau, about 9% of Americans are covered under health insurance purchased directly.[50] The range of products available is similar to those provided through employers. However, average out-of-pocket spending is higher in the individual market, with higher deductibles, co-payments and other cost-sharing provisions.[69][77] Major medical is the most commonly purchased form of individual health insurance. Although a major medical health insurance policy is primarily a catastrophic plan, qualified preventive benefits are still covered at 100% without any waiting period or copay.[78]

text: In the individual market, the consumer pays the entire premium without benefit of an employer contribution.[77][79] While self-employed individuals receive a tax deduction for their health insurance and can buy health insurance with additional tax benefits, most consumers in the individual market do not receive any tax benefit.[80]

text: Premiums vary significantly by age.[77][81][82] In states that allow individual medical plan underwriting, premiums also vary by health status.[77] However, with the Patient Protection and Affordable Care Act, effective since 2014, insurers are prohibited from discriminating against or charging higher rates for individuals based on pre-existing medical conditions.[45][46]

text: In August 2008, the Hartford Courant reported that competition was increasing in the individual health insurance market, with more insurers entering the market, an increased variety of products, and a broader spread of prices.[83]

text: Individual health insurance is primarily regulated at the state level, consistent with the McCarran-Ferguson Act. Model acts and regulations promulgated by the National Association of Insurance Commissioners (NAIC) provide some degree of uniformity state to state. These models do not have the force of law and have no effect unless they are adopted by a state. They are, however, used as guides by most states, and some states adopt them with little or no change.

text: Types of medical insurance[edit]

text: Traditional indemnity or fee-for-service[edit]

text: Early hospital and medical plans offered by insurance companies paid either a fixed amount for specific diseases or medical procedures (schedule benefits) or a percentage of the provider's fee. The relationship between the patient and the medical provider was not changed. The patient received medical care and was responsible for paying the provider. If the service was covered by the policy, the insurance company was responsible for reimbursing or indemnifying the patient based on the provisions of the insurance contract ("reimbursement benefits"). Health insurance plans that are not based on a network of contracted providers, or that base payments on a percentage of provider charges, are still described as indemnity or fee-for-service plans.[18]

text: Blue Cross Blue Shield Association[edit]

text: The Blue Cross Blue Shield Association (BCBSA) is a federation of 38 separate health insurance organizations and companies in the United States. Combined, they directly or indirectly provide health insurance to over 100 million Americans.[84] BCBSA insurance companies are franchisees, independent of the association (and traditionally each other), offering insurance plans within defined regions under one or both of the association's brands. Blue Cross Blue Shield insurers offer some form of health insurance coverage in every U.S. state, and also act as administrators of Medicare in many states or regions of the United States, and provide coverage to state government employees as well as to federal government employees under a nationwide option of the Federal Employees Health Benefit Plan.[85]

text: Health Maintenance Organizations[edit]

text: A health maintenance organization (HMO) is a type of managed care organization (MCO) that provides a form of health care coverage that is fulfilled through hospitals, doctors, and other providers with which the HMO has a contract. The Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options.[86] Unlike traditional indemnity insurance, an HMO covers only care rendered by those doctors and other professionals who have agreed to treat patients in accordance with the HMO's guidelines and restrictions in exchange for a steady stream of customers. Benefits are provided through a network of providers. Providers may be employees of the HMO ("staff model"), employees of a provider group that has contracted with the HMO ("group model"), or members of an independent practice association ("IPA model"). HMOs may also use a combination of these approaches ("network model").[18][87]

text: Managed care[edit]

text: The term managed care is used to describe a variety of techniques intended to reduce the cost of health benefits and improve the quality of care. It is also used to describe organizations that use these techniques ("managed care organization").[88] Many of these techniques were pioneered by HMOs, but they are now used in a wide variety of private health insurance programs. Through the 1990s, managed care grew from about 25% US employees with employer-sponsored coverage to the vast majority.[89]

text:
Rise of managed care in the US[90][clarification needed]

Year
Conventional
plans
HMOs
PPOs
POS
plans
HDHP/SOs

1998
14%
27%
35%
24%
—

1999
10%
28%
39%
24%
—

2000
8%
29%
42%
21%
—

2001
7%
24%
46%
23%
—

2002
4%
27%
52%
18%
—

2003
5%
24%
54%
17%
—

2004
5%
25%
55%
15%
—

2005
3%
21%
61%
15%
—

2006
3%
20%
60%
13%
4%

2007
3%
21%
57%
15%
5%

2008
2%
20%
58%
12%
8%

2009
1%
20%
60%
10%
8%

2010
1%
19%
58%
8%
13%

2011
1%
17%
55%
10%
17%

2012
<1%
16%
56%
9%
19%

2013
<1%
14%
57%
9%
20%

2014
<1%
13%
55%
23%
27%

2015
1%
17%
50%
26%
26%

2016
2%
23%
35%
32%
28%

tag: table

text: Network-based managed care[edit]

text: Many managed care programs are based on a panel or network of contracted health care providers. Such programs typically include:

text:
A set of selected providers that furnish a comprehensive array of health care services to enrollees;
Explicit standards for selecting providers;
Formal utilization review and quality improvement programs;
An emphasis on preventive care; and
Financial incentives to encourage enrollees to use care efficiently.

tag: ul

text: Provider networks can be used to reduce costs by negotiating favorable fees from providers, selecting cost effective providers, and creating financial incentives for providers to practice more efficiently.[21] A survey issued in 2009 by America's Health Insurance Plans found that patients going to out-of-network providers are sometimes charged extremely high fees.[91][92]

text: Network-based plans may be either closed or open. With a closed network, enrollees' expenses are generally only covered when they go to network providers. Only limited services are covered outside the network—typically only emergency and out-of-area care. Most traditional HMOs were closed network plans. Open network plans provide some coverage when an enrollee uses non-network provider, generally at a lower benefit level to encourage the use of network providers. Most preferred provider organization plans are open-network (those that are not are often described as exclusive provider organizations, or EPOs), as are point of service (POS) plans.

text: The terms "open panel" and "closed panel" are sometimes used to describe which health care providers in a community have the opportunity to participate in a plan. In a "closed panel" HMO, the network providers are either HMO employees (staff model) or members of large group practices with which the HMO has a contract. In an "open panel" plan the HMO or PPO contracts with independent practitioners, opening participation in the network to any provider in the community that meets the plan's credential requirements and is willing to accept the terms of the plan's contract.

text: Other managed care techniques[edit]

text: Other managed care techniques include such elements as disease management, case management, wellness incentives, patient education, utilization management and utilization review. These techniques can be applied to both network-based benefit programs and benefit programs that are not based on a provider network. The use of managed care techniques without a provider network is sometimes described as "managed indemnity."

text: Blurring lines[edit]

text: Over time, the operations of many Blue Cross and Blue Shield operations have become more similar to those of commercial health insurance companies.[93] However, some Blue Cross and Blue Shield plans continue to serve as insurers of last resort.[94] Similarly, the benefits offered by Blues plans, commercial insurers, and HMOs are converging in many respects because of market pressures. One example is the convergence of preferred provider organization (PPO) plans offered by Blues and commercial insurers and the point of service plans offered by HMOs. Historically, commercial insurers, Blue Cross and Blue Shield plans, and HMOs might be subject to different regulatory oversight in a state (e.g., the Department of Insurance for insurance companies, versus the Department of Health for HMOs). Today, it is common for commercial insurance companies to have HMOs as subsidiaries, and for HMOs to have insurers as subsidiaries (the state license for an HMO is typically different from that for an insurance company).[18][87][95] At one time the distinctions between traditional indemnity insurance, HMOs and PPOs were very clear; today, it can be difficult to distinguish between the products offered by the various types of organization operating in the market.[96]

text: The blurring of distinctions between the different types of health care coverage can be seen in the history of the industry's trade associations. The two primary HMO trade associations were the Group Health Association of America and the American Managed Care and Review Association. After merging, they were known as American Association of Health Plans (AAHP). The primary trade association for commercial health insurers was the Health Insurance Association of America (HIAA). These two have now merged, and are known as America's Health Insurance Plans (AHIP).

text: New types of medical plans[edit]

text: In recent years,[when?] various new types of medical plans have been introduced.

text: Health care markets and pricing[edit]

text: The US health insurance market is highly concentrated, as leading insurers have carried out over 400 mergers from the mid-1990s to the mid-2000s (decade). In 2000, the two largest health insurers (Aetna and UnitedHealth Group) had total membership of 32 million. By 2006 the top two insurers, WellPoint and UnitedHealth, had total membership of 67 million. The two companies together had more than 36% of the national market for commercial health insurance. The AMA has said that it "has long been concerned about the impact of consolidated markets on patient care." A 2007 AMA study found that in 299 of the 313 markets surveyed, one health plan accounted for at least 30% of the combined health maintenance organization (HMO)/preferred provider organization (PPO) market. In 90% of markets, the largest insurer controls at least 30% of the market, and the largest insurer controls more than 50% of the market in 54% of metropolitan areas.[108] The US Department of Justice has recognized this percentage of market control as conferring substantial monopsony power in the relations between insurer and physicians.[109]

text: Most provider markets (especially hospitals) are also highly concentrated, - roughly 80%, according to criteria established by the FTC and Department of Justice[110] - so insurers usually have little choice about which providers to include in their networks, and consequently little leverage to control the prices they pay. Large insurers frequently negotiate most-favored nation clauses with providers, agreeing to raise rates significantly while guaranteeing that providers will charge other insurers higher rates.[111]

text: According to some experts, such as Uwe Reinhardt,[112] Sherry Glied, Megan Laugensen,[113] Michael Porter, and Elizabeth Teisberg,[114] this pricing system is highly inefficient and is a major cause of rising health care costs. Health care costs in the United States vary enormously between plans and geographical regions, even when input costs are fairly similar, and rise very quickly. Health care costs have risen faster than economic growth at least since the 1970s. Public health insurance programs typically have more bargaining power as a result of their greater size and typically pay less for medical services than private plans, leading to slower cost growth, but the overall trend in health care prices have led public programs' costs to grow at a rapid pace as well.

text: Other types of health insurance (non-medical)[edit]

text: While the term "health insurance" is most commonly used by the public to describe coverage for medical expenses, the insurance industry uses the term more broadly to include other related forms of coverage, such as disability income and long-term care insurance.

text: Disability income insurance[edit]

text: Disability income (DI) insurance pays benefits to individuals who become unable to work because of injury or illness. DI insurance replaces income lost while the policyholder is unable to work during a period of disability (in contrast to medical expense insurance, which pays for the cost of medical care).[115] For most working age adults, the risk of disability is greater than the risk of premature death, and the resulting reduction in lifetime earnings can be significant. Private disability insurance is sold on both a group and an individual basis. Policies may be designed to cover long-term disabilities (LTD coverage) or short-term disabilities (STD coverage).[116] Business owners can also purchase disability overhead insurance to cover the overhead expenses of their business while they are unable to work.[117]

text: A basic level of disability income protection is provided through the Social Security Disability Insurance (SSDI) program for qualified workers who are totally and permanently disabled (the worker is incapable of engaging in any "substantial gainful work" and the disability is expected to last at least 12 months or result in death).

text: Long-term care insurance[edit]

text: Long-term care (LTC) insurance reimburses the policyholder for the cost of long-term or custodial care services designed to minimize or compensate for the loss of functioning due to age, disability or chronic illness.[118] LTC has many surface similarities to long-term disability insurance. There are at least two fundamental differences, however. LTC policies cover the cost of certain types of chronic care, while long-term-disability policies replace income lost while the policyholder is unable to work. For LTC, the event triggering benefits is the need for chronic care, while the triggering event for disability insurance is the inability to work.[115]

text: Private LTC insurance is growing in popularity in the US. Premiums have remained relatively stable in recent years. However, the coverage is quite expensive, especially when consumers wait until retirement age to purchase it. The average age of new purchasers was 61 in 2005, and has been dropping.[119]

text: Supplemental coverage[edit]

text: Private insurers offer a variety of supplemental coverages in both the group and individual markets. These are not designed to provide the primary source of medical or disability protection for an individual, but can assist with unexpected expenses and provide additional peace of mind for insureds. Supplemental coverages include Medicare supplement insurance, hospital indemnity insurance, dental insurance, vision insurance, accidental death and dismemberment insurance and specified disease insurance.[18]

text: Supplemental coverages are intended to:

text:
Supplement a primary medical expense plan by paying for expenses that are excluded or subject to the primary plan's cost-sharing requirements (e.g., co-payments, deductibles, etc.);
Cover related expenses such as dental or vision care;
Assist with additional expenses that may be associated with a serious illness or injury.[18]

text: Medicare Supplement Coverage (Medigap)[edit]

text: Medicare Supplement policies are designed to cover expenses not covered (or only partially covered) by the "original Medicare" (Parts A & B) fee-for-service benefits. They are only available to individuals enrolled in Medicare Parts A & B. Medigap plans may be purchased on a guaranteed issue basis (no health questions asked) during a six-month open enrollment period when an individual first becomes eligible for Medicare.[120] The benefits offered by Medigap plans are standardized.

text: Hospital indemnity insurance[edit]

text: Hospital indemnity insurance provides a fixed daily, weekly or monthly benefit while the insured is confined in a hospital. The payment is not dependent on actual hospital charges, and is most commonly expressed as a flat dollar amount. Hospital indemnity benefits are paid in addition to any other benefits that may be available, and are typically used to pay out-of-pocket and non-covered expenses associated with the primary medical plan, and to help with additional expenses (e.g., child care) incurred while in the hospital.[18][87]

text: Scheduled health insurance plans[edit]

text: Scheduled health insurance plans are an expanded form of Hospital Indemnity plans. In recent years, these plans have taken the name mini-med plans or association plans. These plans may provide benefits for hospitalization, surgical, and physician services. However, they are not meant to replace a traditional comprehensive health insurance plan. Scheduled health insurance plans are more of a basic policy providing access to day-to-day health care such as going to the doctor or getting a prescription drug, but these benefits will be limited and are not meant to be effective for catastrophic events. Payments are based upon the plan's "schedule of benefits" and are usually paid directly to the service provider. These plans cost much less than comprehensive health insurance. Annual benefit maximums for a typical scheduled health insurance plan may range from $1,000 to $25,000.[121]

text: Dental insurance[edit]

text: Dental insurance helps pay for the cost of necessary dental care. Few medical expense plans include coverage for dental expenses. About 97% of dental benefits in the United States is provided through separate policies from carriers—both stand-alone and medical affiliates—that specialize in this coverage. Typically, these dental plans offer comprehensive preventive benefits. However, major dental expenses, such as crowns and root canals, are just partially covered. Also, most carriers offer a lower rate if you select a plan that utilizes their Network providers. Discount dental programs are also available. These do not constitute insurance, but provide participants with access to discounted fees for dental work.

text: Vision care insurance[edit]

text: Vision care insurance provides coverage for routine eye care and is typically written to complement other medical benefits. Vision benefits are designed to encourage routine eye examinations and ensure that appropriate treatment is provided.[18]

text: Specified disease[edit]

text: Specified disease provides benefits for one or more specifically identified conditions. Benefits can be used to fill gaps in a primary medical plan, such as co-payments and deductibles, or to assist with additional expenses such as transportation and child care costs.[18]

text: Accidental death and dismemberment insurance[edit]

text: AD&D insurance is offered by group insurers and provides benefits in the event of accidental death. It also provides benefits for certain specified types of bodily injuries (e.g., loss of a limb or loss of sight) when they are the direct result of an accident.[18]

text:
Insurance companies have high administrative costs.[122] Private health insurers are a significant portion of the U.S. economy directly employing (in 2004) almost 470,000 people at an average salary of $61,409.[123]
Health insurance companies are not actually providing traditional insurance, which involves the pooling of risk, because the vast majority of purchasers actually do face the harms that they are "insuring" against. Instead, as Edward Beiser and Jacob Appel have separately argued, health insurers are better thought of as low-risk money managers who pocket the interest on what are really long-term healthcare savings accounts.[124][125]
According to a study by a pro-health reform group published February 11, the nation's largest five health insurance companies posted a 56 percent gain in 2009 profits over 2008. The insurers (Wellpoint, UnitedHealth, Cigna, Aetna and Humana) cover the majority of Americans with health insurance.[126]


document_title: Laura Ingalls Wilder

question_text: when was laura ingalls wilder first book published

text: Laura Ingalls Wilder

text: Birth and ancestry[edit]

text: Laura Elizabeth Ingalls was born on February 7, 1867, 7 miles (11 km) north of the village of Pepin in the Big Woods region of Wisconsin,[2] to Charles Phillip Ingalls and Caroline Lake (née Quiner) Ingalls. She was the second of five children, following Mary Amelia.[3][4][5][6] Their three younger siblings were Caroline Celestia, Charles Frederick (who died in infancy), and Grace Pearl. Wilder's birth site is commemorated by a replica log cabin, the Little House Wayside.[7] Life there formed the basis for her first book, Little House in the Big Woods (1932).[2] Wilder was a descendant of the Delano family, an ancestral family of U.S. President Franklin Delano Roosevelt.[8] A progenitor of the Delano family emigrated to the Plymouth Colony in the early 1620s; another family ancestor, Edmund Rice, emigrated in 1638 to the Massachusetts Bay Colony.[9] One paternal ancestor, Edmund Ingalls, was born on June 27, 1586, in Skirbeck, Lincolnshire, England, and emigrated to America, where he died in Lynn, Massachusetts, on September 16, 1648.[8]

text: Family on the move[edit]

text: Wilder moved with her family from Wisconsin in 1869, when she was two years old. They stopped in Rothville, Missouri, and settled in Kansas, in Indian country near what is now Independence. Her younger sister Carrie (1870–1946) was born there in August 1870, not long before they moved again. According to Wilder in later years, her father had been told that the location would soon be open to white settlers but that was incorrect; their homestead was actually on the Osage Indian reservation and they had no legal right to occupy it. They had just begun to farm when they heard rumors that the settlers would be evicted, and they departed in spring of 1871. Although Laura portrayed the leave and that of other settlers as prompted by rumors of eviction in both her novel and in her Pioneer Girl memoirs, in the memoirs she also noted that her parents needed to recover their Wisconsin land because the buyer had not paid the entire mortgage. Several Kansas neighbors apparently were allowed to buy the land they had settled on, so the rumors may have been untrue.[10]

text: From Kansas, the Ingalls family returned to Wisconsin, where they lived for the next three years. Those experiences formed the basis for the novels Little House in the Big Woods (1932) and Little House on the Prairie (1935). The fictional chronology of Wilder's books in this regard does not match fact: Wilder was two to four years old in Kansas and four to seven in Wisconsin; in the novels she is four to five in Wisconsin (Big Woods) and six to seven in Kansas (Prairie). According to a letter from her daughter, Rose Wilder Lane, to biographer William Anderson, the publisher had Wilder change her age in Prairie because it seemed unrealistic for a three-year-old to have memories so specific about her story of life in Kansas.[11] To be consistent with her already established chronology, Wilder portrayed herself six to seven years old in Prairie and seven to nine years old in On the Banks of Plum Creek (1937), the third volume of her fictionalized history, which takes place around 1874.

text: On the Banks of Plum Creek shows the family moving from Kansas to an area near Walnut Grove, Minnesota, and settling in a dugout "on the banks of Plum Creek".[12] They really moved there from Wisconsin when Wilder was about seven years old, after briefly living with the family of Laura's Uncle Peter Ingalls, first in their house in the Big Woods of Wisconsin and then on rented land near Lake City, Minnesota. In Walnut Grove, Laura's family first lived in a dugout on a preemption claim; after wintering in the dugout, they moved into a new house built on the same land. Two summers of ruined crops led the Ingalls to move to Iowa. On the way they stayed again with Laura's Uncle Peter Ingalls, this time on his own farm near South Troy, Minnesota. Wilder's younger and only brother, Charles Frederick Ingalls ("Freddie"), was born there on November 1, 1875, and died nine months later on August 27, 1876. In Burr Oak, Iowa, the Ingalls family helped run a hotel. Wilder's youngest sibling, Grace, was born there on May 23, 1877.

text: The family moved from Burr Oak, Iowa back to Walnut Grove, Minnesota where Wilder's father served as the town butcher and justice of the peace. He accepted a railroad job in the spring of 1879, one which took him to eastern Dakota Territory, where they joined him that fall. Wilder did not write about the period in 1876–1877 when they lived near Burr Oak, but skipped directly to Dakota Territory, portrayed in By the Shores of Silver Lake (1939). Thus the fictional timeline caught up with her real life.

text: De Smet[edit]

text: Wilder's father filed for a formal homestead over the winter of 1879–1880. De Smet, South Dakota, became her parents' and sister Mary Ingalls' home for the remainder of their lives. After spending the mild winter of 1879–1880 in the surveyor's house, they watched the town of De Smet rise up from the prairie in 1880. The following winter, 1880–1881, one of the most severe on record in the Dakotas, was later described by Wilder in her novel, The Long Winter (1940). Once the family was settled in De Smet, Wilder attended school, worked several part-time jobs, and made friends. Among them was bachelor homesteader Almanzo Wilder. This time in her life is documented in the books Little Town on the Prairie (1941) and These Happy Golden Years (1943).

text: Young teacher[edit]

text: On December 10, 1882, two months before her 16th birthday, Wilder accepted her first teaching position.[13] She taught three terms in one-room schools when she was not attending school in De Smet. (In Little Town on the Prairie she receives her first teaching certificate on December 24, 1882, but that was an enhancement for dramatic effect.[citation needed]) Her original "Third Grade" teaching certificate can be seen on page 25 of William Anderson's book Laura's Album (1998).[14] She later admitted she did not particularly enjoy teaching but felt the responsibility from a young age to help her family financially, and wage-earning opportunities for women were limited. Between 1883 and 1885, she taught three terms of school, worked for the local dressmaker, and attended high school, although she did not graduate.

text: Wilder's teaching career and studies ended when she married Almanzo Wilder, whom she called "Manly",[15] on August 25, 1885. As he had a sister named Laura, his nickname for Wilder became "Bess", from her middle name, Elizabeth.[15] Wilder was 18 and he was 28. He had achieved a degree of prosperity on his homestead claim, and their prospects seemed bright. She joined him in a new home, north of De Smet.[citation needed]

text: Children[edit]

text: On December 5, 1886, Wilder gave birth to her daughter Rose Wilder. In 1889, Wilder gave birth to a son who died at 12 days of age before being named. He was buried at De Smet, Kingsbury County, in South Dakota.[16][17] On the grave marker, he is remembered as "Baby Son of A. J. Wilder".[citation needed]

text: Early marriage[edit]

text: Their first few years of marriage for the Wilders were frequently difficult. Complications from a life-threatening bout of diphtheria left Wilder's husband partially paralyzed. While he eventually regained nearly full use of his legs, he needed a cane to walk for the remainder of his life. This setback, among many others, began a series of disastrous events that included the death of their newborn son; the destruction of their barn along with its hay and grain by a mysterious fire;[18] the total loss of their home from a fire accidentally set by their daughter;[19] and several years of severe drought that left them in debt, physically ill, and unable to earn a living from their 320 acres (129.5 hectares) of prairie land. These trials were documented in Wilder's book The First Four Years (published in 1971). Around 1890, the couple left De Smet and spent about a year resting at the home of Wilder's husband's parents on their Spring Valley, Minnesota, farm before moving briefly to Westville, Florida, in search of a climate to improve Wilder's husband's health. They found, however, that the dry plains they were used to were very different from the humidity they encountered in Florida. The weather, along with feeling out of place among the locals, encouraged their return to De Smet in 1892, where they purchased a small home.[citation needed]

text: Move to Mansfield, Missouri[edit]

text: In 1894, the Wilder family moved to Mansfield, Missouri, and used their savings to make the down payment on an undeveloped property just outside town. They named the place Rocky Ridge Farm[20] and moved into a ramshackle log cabin. At first, Wilder and her husband earned income only from wagon loads of fire wood they would sell in town for 50 cents. Financial security came slowly. Apple trees they planted did not bear fruit for seven years. Wilder's parents-in-law visited around that time and gave them the deed to the house they had been renting in Mansfield, which was the economic boost Wilder's family needed. They then added to the property outside town, and eventually accrued nearly 200 acres (80.9 hectares). Around 1910, they sold the house in town, moved back to the farm, and completed the farmhouse with the proceeds. What began as about 40 acres (16.2 hectares) of thickly wooded, stone-covered hillside with a windowless log cabin became in 20 years a relatively prosperous poultry, dairy, and fruit farm, and a 10-room farmhouse.[citation needed]

text: Wilder and her husband had learned from cultivating wheat as their sole crop in De Smet. They diversified Rocky Ridge Farm with poultry, a dairy farm, and a large apple orchard. Wilder became active in various clubs and was an advocate for several regional farm associations. She was recognized as an authority in poultry farming and rural living, which led to invitations to speak to groups around the region.[citation needed]

text: Writing career[edit]

text: An invitation to submit an article to the Missouri Ruralist in 1911 led to Wilder's permanent position as a columnist and editor with that publication, which she held until the mid-1920s. She also took a paid position with the local Farm Loan Association, dispensing small loans to local farmers.

text: Wilder's column in the Ruralist, "As a Farm Woman Thinks", introduced her to a loyal audience of rural Ozarkians, who enjoyed her regular columns. Her topics ranged from home and family, including her 1915 trip to San Francisco, California, to visit her daughter and the Pan-Pacific exhibition, to World War I and other world events, and to the fascinating world travels of her daughter as well as Wilder's own thoughts on the increasing options offered to women during this era. While the couple was never wealthy until the "Little House" books began to achieve popularity, the farming operation and Wilder's income from writing and the Farm Loan Association provided them with a stable living.

text: "[By] 1924", according to the Professor John E. Miller, "[a]fter more than a decade of writing for farm papers, Wilder had become a disciplined writer, able to produce thoughtful, readable prose for a general audience." At this time, her now-married daughter, Rose Wilder Lane, helped her publish two articles describing the interior of the farmhouse, in Country Gentleman magazine.[21]

text: It was also around this time that Lane began intensively encouraging Wilder to improve her writing skills with a view toward greater success as a writer than Lane had already achieved.[22] The Wilders, according to Miller, had come to "[depend] on annual income subsidies from their increasingly famous and successful daughter." They both had concluded that the solution for improving their retirement income was for Wilder to become a successful writer, herself. However, the "project never proceeded very far."[23]

text: In 1928, Lane hired out the construction of an English-style stone cottage for her parents on property adjacent to the farmhouse they had personally built and still inhabited. She remodeled and took it over.[24]

text: Little House books[edit]

text: The Stock Market Crash of 1929 wiped the Wilders out; their daughter's investments were devastated as well. They still owned the 200 acre (81 hectare) farm, but they had invested most of their savings with their daughter Rose Wilder Lane's broker. In 1930, Wilder requested Lane's opinion about an autobiographical manuscript Wilder had written about her pioneering childhood. The Great Depression, coupled with the deaths of Wilder's mother in 1924 and her older sister in 1928, seem to have prompted her to preserve her memories in a life story called Pioneer Girl. Wilder also hoped that her writing would generate some additional income. The original title of the first of the books was When Grandma Was a Little Girl. On the advice of Lane's publisher, Wilder greatly expanded the story. As a result of Lane's publishing connections as a successful writer and after editing by Lane, Harper & Brothers published Wilder's book in 1932 as Little House in the Big Woods. After its success, Wilder continued writing. The close and often rocky collaboration between her and Lane continued, in person until 1935 when Lane permanently left Rocky Ridge Farm, and afterward by correspondence.

text: The collaboration worked both ways: two of Lane's most successful novels, Let the Hurricane Roar (1932) and Free Land (1938), were written at the same time as the "Little House" series and basically retold Ingalls and Wilder family tales in an adult format.[25]

text: Authorship controversy[edit]

text: Some, including Wilder Lane's biographer Professor William Holtz, have alleged that Rose Wilder Lane was Wilder's ghostwriter.[26] Some others, such as Timothy Abreu of Gush Publishing, argue that Wilder was an "untutored genius",[citation needed] relying on her daughter mainly for some early encouragement and Lane's connections with publishers and literary agents. Still others contend that Lane took each of Wilder's unpolished rough drafts in hand and completely, but silently, transformed them into the series of books known today.[citation needed] The existing evidence that includes ongoing correspondence between the women about the books' development, Lane's extensive diaries, and Wilder's handwritten manuscripts with edit notations shows an ongoing collaboration between the two women.

text: Miller, using this record, describes varying levels of involvement by Lane. Little House in the Big Woods (1932) and These Happy Golden Years (1943), he notes, received the least editing. "The first pages ... and other large sections of [Big Woods]", he observes, "stand largely intact, indicating ... from the start ...[Laura's] talent for narrative description."[27] Some volumes saw heavier participation by Lane,[28] while The First Four Years (1971) appears to be exclusively a Wilder work.[29] Concludes Miller, "In the end, the lasting literary legacy remains that of the mother more than that of the daughter ... Lane possessed style; Wilder had substance."[25]

text: The controversy over authorship is often tied to the movement to read the Little House series through an ideological lens. Lane emerged in the 1930s as an avowed conservative polemicist and critic of the Franklin D. Roosevelt administration and his New Deal programs. According to a 2012 article in the New Yorker, "When Roosevelt was elected, she noted in her diary, 'America has a dictator.' She prayed for his assassination, and considered doing the job herself."[30] Whatever Lane's politics, "attacks on [Wilder's] authorship seem aimed at infusing her books with ideological passions they just don’t have."[31]

text: Enduring appeal[edit]

text: The original Little House books, written for elementary school-age children, became an enduring, eight-volume record of pioneering life late in the 19th century based on the Ingalls family's experiences on the American frontier. The First Four Years, about the early days of the Wilder marriage, was discovered by her literary executor Roger MacBride after Lane's 1968 death and published in 1971, unedited by Lane or MacBride. It is now marketed as the ninth volume.[29]

text: Since the publication of Little House in the Big Woods (1932), the books have been continuously in print and have been translated into 40 other languages. Wilder's first — and smallest — royalty check from Harper, in 1932, was for $500, equivalent to $8,970 in 2017. By the mid-1930s the royalties from the Little House books brought a steady and increasingly substantial income to the Wilders for the first time in their 50 years of marriage. The collaboration also brought the two writers at Rocky Ridge Farm the money they needed to recoup the loss of their investments in the stock market. Various honors, huge amounts of fan mail, and other accolades were bestowed on Wilder.[citation needed]

text: Autobiography: Pioneer Girl[edit]

text: In 1929–1930, already in her early 60s, Wilder began writing her autobiography, titled Pioneer Girl. At the time, it was rejected by publishers and was never released. At her daughter's urging, Wilder rewrote most of her stories for children. The result was the Little House series of books. In 2014, the South Dakota State Historical Society published an annotated version of Wilder's autobiography, titled Pioneer Girl: The Annotated Autobiography.[32][33]

text: Pioneer Girl includes stories that Wilder felt were inappropriate for children: e.g., a man accidentally immolating himself while drunk, and an incident of extreme violence of a local shopkeeper against his wife, which ended with the man's setting their house on fire. She also describes previously unknown facets of her father's character. According to its publisher, "Wilder's fiction, her autobiography, and her real childhood are all distinct things, but they are closely intertwined." The book's aim was to explore the differences, including incidents with conflicting or non-existing accounts in one or another of the sources.[34]

text: Later life and death[edit]

text: Upon her daughter's departure from Rocky Ridge Farm, Wilder and her husband moved back into the farmhouse they had built, which had most recently been occupied by friends.[24] From 1935 on, Wilder and her husband were alone at Rocky Ridge Farm. Most of the surrounding area (including the property with the stone cottage Lane had built for them) was sold, but they still kept some farm animals, and tended their flower beds and vegetable gardens. Almost daily, carloads of fans stopped by, eager to meet "Laura" of the Little House books.

text: The Wilders lived independently and without financial worries until the death of Wilder's husband at the farm in 1949 at the age of 92. Wilder remained on the farm. For the next eight years, she lived alone, looked after by a circle of neighbors and friends. She continued an active correspondence with her editors, fans, and friends during these years.

text: In autumn 1956, the 89-year-old Wilder was severely ill from undiagnosed diabetes and cardiac issues. She was hospitalized by her daughter, who had arrived for Thanksgiving. Wilder was able to return home on the day after Christmas. However, her health declined after her release from the hospital, and she died in her sleep, at home, on February 10, 1957, three days after her 90th birthday.[35] Wilder was buried beside her husband at Mansfield Cemetery in Mansfield, Missouri. Their daughter, Rose Wilder Lane, was buried next to them upon her death in 1968.[citation needed]

text: Estate[edit]

text: Following Wilder's death, possession of Rocky Ridge Farmhouse passed to the farmer who had earlier bought the property under a life lease arrangement.[36] The local population put together a non-profit corporation to purchase the house and its grounds for use as a museum. After some wariness at the notion of seeing the house rather than the books be a shrine to Wilder, Lane came to believe that making a museum of it would draw long-lasting attention to the books. She donated the money needed to purchase the house and make it a museum, agreed to make significant contributions each year for its upkeep, and gave many of her parents' belongings.[37]

text: In compliance with Wilder's will, her daughter inherited ownership of the Little House literary estate with the stipulation that it be for only her lifetime, with all rights reverting to the Mansfield library after Lane's death. Following Lane's death in 1968, her will beneficiary, Roger MacBride, gained control of the books' copyrights. MacBride was to Lane an informally adopted grandson, as well as her business agent and lawyer. All of his actions carried her apparent approval; at Lane's request, the copyrights to each of Wilder's "Little House" books, as well as those of Lane's own literary works, had been renewed in MacBride's name when the original copyrights expired, during the decade between Wilder's death and Lane's death.[citation needed]

text: Controversy arose following MacBride's death in 1995, when the Laura Ingalls Wilder Branch of the Wright County Library in Mansfield — the library founded in part by Wilder — decided it was worth trying to recover the rights. The ensuing court case was settled in an undisclosed manner, but MacBride's heirs retained the rights to Wilder's books. From the settlement, the library received enough to start work on a new building.[citation needed]

text: The popularity of the Little House book series has grown over the years following Wilder's death, spawning a multimillion-dollar franchise of mass merchandising.[citation needed] Results of the franchise have included additional spinoff book series[citation needed] — some written by MacBride and his daughter, Abigail MacBride Allen — and the long-running television series, starring Melissa Gilbert as Wilder and Michael Landon as her father.

text: Works[edit]

text: Because she died in 1957, the works of Wilder are now public domain in countries where the term of copyright lasts 50 years after the death of the author, or less; generally this does not include works first published posthumously. Works first published before 1923 or where copyright was not renewed, primarily her newspaper columns, are also public domain in the United States.[citation needed]

text: Little House books[edit]

text: The eight "original" Little House books were published by Harper & Brothers with illustrations by Helen Sewell (the first three) or by Sewell and Mildred Boyle.

text:
Little House in the Big Woods (1932) — named to the inaugural Lewis Carroll Shelf Award list in 1958
Farmer Boy (1933) — about Almanzo Wilder growing up in New York
Little House on the Prairie (1935)
On the Banks of Plum Creek (1937)[a]
By the Shores of Silver Lake (1939)[a]
The Long Winter (1940)[a]
Little Town on the Prairie (1941)[a]
These Happy Golden Years (1943)[a]

text: Other works[edit]

text:
On the Way Home (1962, published posthumously) — diary of the Wilders' move from De Smet, South Dakota, to Mansfield, Missouri, edited and supplemented by Rose Wilder Lane[38]
The First Four Years (1971, published posthumously by Harper & Row), illustrated by Garth Williams — commonly considered the ninth Little House book
West from Home (1974, published posthumously), ed. Roger Lea MacBride — Wilder's letters to her husband while visiting their daughter in San Francisco[39]
Little House in the Ozarks: The Rediscovered Writings (1991)[40] LCCN 91-10820 — collection of pre-1932 articles[41]
The Road Back Home, part three (the only part previously unpublished) of A Little House Traveler: Writings from Laura Ingalls Wilder's Journeys Across America (2006, Harper) LCCN 2005-14975) — Wilder's record of a 1931 trip with her husband to De Smet, South Dakota, and the Black Hills
A Little House Sampler (1988 or 1989, U. of Nebraska), with Rose Wilder Lane, ed. William Anderson, OCLC 16578355[42]
Writings to Young Women — Volume One: On Wisdom and Virtues, Volume Two: On Life As a Pioneer Woman, Volume Three: As Told By Her Family, Friends, and Neighbors[citation needed]
A Little House Reader: A Collection of Writings (1998, Harper), ed. William Anderson[42]
Laura Ingalls Wilder & Rose Wilder Lane, 1937–1939 (1992, Herbert Hoover Presidential Library), ed. Timothy Walch — selections from letters exchanged by Wilder and her daughter, with family photographs, OCLC 31440538
Laura's Album: A Remembrance Scrapbook of Laura Ingalls Wilder (1998, Harper), ed. William Anderson, OCLC 865396917
Pioneer Girl: The Annotated Autobiography (South Dakota Historical Society Press, 2014)[32]
Before the Prairie Books: The Writings of Laura Ingalls Wilder 1911–1916: The Small Farm[citation needed]
Before the Prairie Books: The Writings of Laura Ingalls Wilder 1917–1918: the War Years[citation needed]
Before the Prairie Books: The Writings of Laura Ingalls Wilder 1919–1920: The Farm Home[citation needed]
Before the Prairie Books: The Writings of Laura Ingalls Wilder 1921–1924, A Farm Woman[citation needed]
Laura Ingalls Wilder's Most Inspiring Writings[citation needed]
Laura Ingalls Wilder: A Pioneer Girl's World View: Selected Newspaper Columns (Little House Prairie Series)[citation needed]
The Selected Letters of Laura Ingalls Wilder, edited by William Anderson [43]
Laura Ingalls Wilder Farm Journalist: Writings from the Ozarks, edited by Stephen W. Hines[44]

text: Legacy[edit]

text: Documentary[edit]

text: Little House on the Prairie: The Legacy of Laura Ingalls Wilder (February, 2015) is a one-hour documentary film that looks at the life of Wilder. Wilder's story as a writer, wife, and mother is explored through interviews with scholars and historians, archival photography, paintings by frontier artists, and dramatic reenactments.

text: Historic sites and museums[edit]

text:
Laura Ingalls Wilder Home and Museum, Mansfield, Missouri
Laura Ingalls Wilder Museum, Pepin, Wisconsin[45]
Laura Ingalls Wilder Museum, Walnut Grove, Minnesota[46]
Laura Ingalls Wilder Pageant and Museum, De Smet, South Dakota
Laura Ingalls Wilder Park and Museum, Burr Oak, Iowa[47]
Little House on the Prairie Museum, Independence, Kansas[48]
Wilder Homestead, Malone, NY[49]

text: Portrayals on screen and stage[edit]

text: Multiple adaptations of Wilder's Little House on the Prairie book series have been produced for screen and stage. In them, the following actresses have portrayed Wilder:

text:
Melissa Gilbert in the television series Little House on the Prairie and its movie sequels (1974–1984)
Kazuko Sugiyama (voice) in Laura, The Prairie Girl Japanese anime series (1975–1976)
Meredith Monroe, Tess Harper (elder version), Alandra Bingham (younger version, part 1), Michelle Bevan (younger version, part 2) in Part 1 and Part 2 of the Beyond the Prairie: The True Story of Laura Ingalls Wilder television films (2000 and 2002)
Kyle Chavarria in the TV miniseries Little House on the Prairie (2005)
Kara Lindsay in the Little House on the Prairie book musical (2008–2010)

text: Wilder Medal[edit]

text: Wilder was five times a runner-up for the annual Newbery Medal, the premier American Library Association (ALA) book award for children's literature.[a] In 1954, the ALA inaugurated a lifetime achievement award for children's writers and illustrators, named for Wilder, and first awarded to her. The Laura Ingalls Wilder Medal recognizes a living author or illustrator whose books, published in the United States, have made "a substantial and lasting contribution to literature for children". As of 2013, it has been conferred 19 times, biennially starting in 2001.[51]

text: Other[edit]

text:
Google Doodle commemorated her 148th birthday in 2015.[52]
Hall of Famous Missourians at the Missouri State Capitol — a bronze bust depicting Wilder is on permanent display in the rotunda. She was inducted in 1993.
Missouri Walk of Fame — Wilder was honored on the Walk in 2006.[citation needed]
Wilder crater on planet Venus was named after Laura Ingalls Wilder.